Cure health care, or lose it – bit by bit

TheGlobeandMail.com – Opinions – We need to put our money into prevention, and get the sick to pay back, through their income taxes, some of what we spend on them
Published on Friday, Feb. 26, 2010. Tom Kent

We are spared American controversy about health insurance, but health care’s popularity does not mean that our medicare can continue as it is. It is not working well enough. Costs are rising too rapidly. If it is not significantly improved, it will contract. Province by province, some services will be withdrawn. Across Canada, public finance will provide a diminishing proportion of the health care people require. More will be paid for privately, by those who can afford it.

Whether contraction is prevented will depend largely on provincial politicians. It is they who should, for example, press far harder to shift most primary care from small doctors’ offices to clinics where it is delivered by teams in which nurses and other qualified personnel do more of the work.

Ottawa will not help this and other reforms by setting vague targets and again pouring in money. Fixing medicare for a generation, as was proclaimed last time, requires two fundamental changes. One is to bring consciousness of cost into the decisions of doctor and patient. The other is to undertake a national policy for good health, for promoting wellness besides treating sickness.

Medicare began because the costs of some treatments were financially ruinous for almost everyone. The need has intensified as advancing medical science develops more sophisticated treatments for ever more of our ills. Doctors want to cure, people want to be cured. For governments, medicare has become a financial treadmill on which they must run faster and faster to avoid blame for sicknesses uncured.

What is crowded out is the prevention of sickness. It is not only better than curing. It is cheaper, eventually. But it takes time. Immediately, it means additional costs on top of treating those who are already sick. Under pressure, it is put off to tomorrow, and tomorrow.

The impending consequence was underlined by Tommy Douglas years ago. If we concentrate on patching people up when they are sick, he warned, the costs will rise so much that people will rebel against the tax burden.

Many measures to promote health – ending child poverty, most notably – are federal business. And while health care itself is provincial, a new Canadian direction will again come only with federal leadership, insistent leadership. The existing funding arrangement has four more years to run. But the emphasis of medical practice cannot be quickly shifted. Now is none too early to make it plain that future federal funding will be provided only to provincial programs directed as firmly to preventing sickness, as to treating it.

That means making medicare more comprehensive, for children first. For them, it means adding regular checkups, pharmacare, eye and dental treatments, nutritional supplements. The details will require careful consideration and negotiation. The benefits will take time to mature, and meantime costs will be higher. The realignment cannot be responsibly urged without some offsetting economies.

A free service cannot be free from misuse. Doctors, harried by some people with trivial complaints or none, consulted too little and too late by others, have to make difficult decisions with little reason why they or their patients should weigh the costs.

The commonly suggested remedy is user fees. At rates sufficient to be effective, they would destroy the purpose of medicare. There is an equitable alternative, suggested by some of us when thinking about health policy 50 years ago. Then tax recovery of social benefits was an unconventional idea, but people have since become accustomed to it, notably in the case of Old Age Security.

It would now be practicable to report the total cost of the public-health services received by an individual or family during the year. But, unlike other T4 forms, only a small part of the money, up to a maximum of 10 per cent of other income, would count as taxable.

For example, someone with $50,000 income otherwise, who got medicare benefits costing $2,000, would next year pay back (at the present 15 per cent rate) $300 of it. If serious illness resulted in costs of $5,000 or more, the payback would be, at most, $750. For high-income people, the proportionate recovery would be somewhat greater of course; at the other extreme, people with too little money to be taxable would not be affected.

Many people now incur drug and other costs they cannot afford and, worse, suffer sickness that could have been prevented. The medicare of 40 years ago was a massive advance, but its intended effectiveness and fairness will not be sustained unless we do much more for the health of Canadians – and we will not find the money for that unless we also make significant economies. The two measures proposed here are twin reforms dependent on each other.